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2 MAINE PRINCIPALS' ASSOCIATION 50 Industrial Drive P.O. Box 2468 Augusta, Maine (207) Fax: (207) Website: Linda Bleile Wiscasset Middle School President Gus LeBlanc Lewiston High School President-elect Mary Martin Elm Street School Mechanic Falls Past-president Jeanne Crocker South Portland High School NASSP State Coordinator Harried Trafford Albert S. Hall School Waterville NAESP State Representative Richard A. Durost Executive Director Michael R. Burnham Assistant Director FOREWORD Who taught you to throw a ball? To shoot baskets? To swing a bat? To run correctly? Chances are good that you remember those fi rst coaches by name, even if they were not parents or family members. If you were lucky, your early coaches were patient and encouraging. They didn t give up on you when the ball seemed too large or when you thought you had failed. They made sure you were safe, but they let you make the mistakes you needed to make and they applauded your successes. We never outgrow the need for supportive coaches, but at no time is that need more intense than during the adolescent years. It is during those years that boys and girls become young men and women; it is during those years that they will decide the kind of people they will become. Too many students lack the family and community support they need to make good choices. For many young people, coaches are the most stable, positive, and signifi cant role models in their lives. It is a position of great trust and responsibility, one not to be entered into lightly. For this reason, the Maine Principals Association administers a set of guidelines to ensure that coaches meet minimum standards, that they are prepared to ensure the safety of student athletes, and that the interscholastic program available to Maine students is of the highest quality. We believe that through these guidelines, we are putting into action our belief that coaches are teachers of students fi rst and coaches of a sport second. These guidelines are contained in this Coaches Handbook, along with other material helpful to coaches, athletic administrators, and principals. It is also important for you to review the MPA Handbook as stipulated in the coaches eligibility policy. Please take some time to review the contents of both of these handbooks and refl ect on the importance of your role. Yours is a high calling, and I hope that this Coaches Handbook will be useful in helping you be the best coach you can be. Your student athletes deserve no less. Sincerely, Richard A. Durost Executive Director Phyllis A. Deringis Assistant Director Jeffrey D. Sturgis Assistant Director MPA is an Equal Opportunity Organization. AFFILIATE: NATIONAL ASSOCIATION OF ELEMENTARY SCHOOL PRINCIPALS AND THE NATIONAL ASSOCIATION OF SECONDARY SCHOOL PRINCIPALS MEMBER: NATIONAL FEDERATION OF STATE HIGH SCHOOL ASSOCIATIONS MEMBER: MAINE EDUCATION LEADERSHIP CONSORTIUM

3 Table of Contents Mission Statement...1 MPA Staff....1 What is the MPA?...2 More About the MPA!...3 Lines of Authority...4 MPA Authority...4 Frequently Asked Questions...4 Local School District Authority...5 Playing Rules and Rules Meeting Attendance...5 Code of Ethics for Secondary School Activities...6 Coaches Code of Ethics...6 Safety First...7 Concussions...7 Pre-Hospital Care of Spinal Injuries...15 Reducing Brain and Spinal Injuries in Football...15 Cold Illness, Heat Illness, and Hydration Position of Statement of Dietary and Other Athletic Performance Enhancing Drug Supplements...23 Advisory On Sports Preseason or Preparticipation Physical Exams...25 Communicable Disease Procedures...25 Eligibility...26 Student Eligibility...26 Coaches' Eligibility...27 Sample Form...30 Ejection Rule...30 Assault Provisions...31 Coaches' Professional Expectations...31 Sport Season Policy...36 Dates...36 Frequently Asked Questions...37 Forfeitures...49 What is Negligence in Coaching?...49 Working with the Media...52 What Every Coach Should Know...53 The Successful Coach...54 Why Coach?...55 NFHS Coaches' Association...55 Coaches' Liaisons to MPA Committees...56 MPA Interscholastic Management Committee...57

4 INTRODUCTION This handbook serves two purposes. First, it addresses important sports medicine issues such as concussions, heat stress, and ways to avoid neck injuries in football. The sport season policy and eligibility rules are clarifi ed through the frequently asked questions which illustrate the interpretation of these rules. The handbook also contains information on important topics such as ethics, safety, and media relations that can make your coaching experience more satisfying and productive. It is not intended to be an exhaustive resource containing all the information that Maine coaches need; rather, it is a primer that can serve to remind coaches of their important responsibilities and advise them where to get further information as needed. MISSION STATEMENT OF THE MAINE PRINCIPALS' ASSOCIATION To assure a quality education for all students, the Maine Principals' Association will: (1) promote the principalship; (2) support principals as educational leaders; and (3) promote and administer interscholastic activities in grades MPA Staff Richard Durost, Executive Director Michael Burnham, Assistant Executive Director Phyllis Deringis, Assistant Executive Director Jeffrey Sturgis, Assistant Executive Director Debra Cates, Secretary/Receptionist Diane Patnaude, Bookkeeper Tammy McNear, Secretary Patty Newman, Executive Assistant 1

5 What is the MPA? The MPA is an association whose membership includes public school principals, assistant principals, private school headmasters, assistant headmasters, technical and career center directors. The MPA has, in part, grown out of a group formed in 1921 to eliminate some of the confusion surrounding high school athletic tournaments in Maine. Since that time, the MPA has joined with elementary and middle schools to develop two goals that shape its activities: (1) to encourage professional improvement and cooperation among principals, and (2) to promote and regulate all educationally sound student activities in Maine high schools. How Does the MPA Work To Achieve These Goals? The Professional Activities Division of the MPA is responsible for the first goal of encouraging professional improvement and cooperation among principals. This division has committees made up of Maine principals who are concerned with educational policies, curriculum, middle level education, supervision and evaluation of staff members and programs, and legislative activities. In addition, the MPA is a sponsor of the Maine Principals Academy and supports the Maine Education Leadership Consortium, an educational collaboration made up of major organizations and associations promoting K-12 public education. The MPA publishes two monthly newsletters for its members --The Maine Apprise and School Law for Principals. Several conferences and workshops are held each year, designed specifically to meet the professional needs of school building administrators. The Interscholastic Activities Division is responsible for the promotion and regulation of interscholastic activities in Maine. The MPA sponsors nine regional and two statewide One Act Play Festivals, a statewide Science & Technology Fair, and the Maine State Debate Championship. The MPA also supports student councils and the National Honor Society by providing staff and funds to help organize these activities. The MPA also sponsors invitational championships or tournaments in the whole range of high school sports cross country, field hockey, football, golf, soccer, volleyball, basketball, cheerleading, ice hockey, skiing, swimming, indoor track, wrestling, baseball, lacrosse, softball, tennis, and outdoor track. Thanks to the work of the MPA Interscholastic Division, each year 155 Maine high schools from Kittery to Madawaska enjoy the benefits of participation in fair, well-regulated, and educationally sound athletic competition. Plus, thousands of Maine parents, friends, relatives, and neighbors enjoy the special excitement of regular season and post-season play in each of the sports mentioned above. How Does the MPA Pay For All of These Events? The MPA receives money from tournament activities, institutional dues, and individual professional dues. The moneys received from tournament activities help defray the costs of activities that don t bring in enough revenue to offset their expenses. For example, the income from the state basketball tournament will be used to pay tournamentrelated expenses, but will also be used to fund non-incomeproducing students' activities. Of the twenty-three activities sponsored by the MPA, a few show a profit, some have income but not enough to cover expenses, and others have no income at all. Want More Information about the MPA? We are happy to answer any questions you have about the MPA and its activities. Please write to us at P.O. Box 2468, Augusta, ME , call us at , or us at MAINE PRINCIPALS ASSOCIATION Committed to the Excellence of the Mind And Body of All School Students in the State. 50 Industrial Drive P.O. Box 2468 Augusta, ME Tel Fax: 207/ Website: 2

6 SCOPE We sometimes forget why high school sports exist. The mission of educational athletics is just that to educate. To that end, MPA member schools develop and agree to enforce essential eligibility standards for student-athletes and other regulations. Local school districts are welcome to establish stricter guidelines. Over 26 committees, made up of principals, assistant principals, athletic administrators, coaches and offi cials liaison, impact the MPA s rules process. The association s 12-member Interscholastic Management Committee is its member school-elected legislative body. The Management Committee, entirely independent of any governmental agency, meets four times annually to pass and modify regulations and to hear rule appeals from member schools. Member schools, leagues, and allied organizations, such as associations of coaches, administrators, and offi cials, are welcome to submit proposals for new or modifi ed regulations to be discussed by the membership. The association s executive staff, part of the 8-person team working for member schools at its headquarters offi ce in Augusta, interpret rules daily. All rule appeals, however, are heard and granted by the Management Committee. EDUCATION Over 6,827 coaches are registered with the MPA. Within twelve (12) months of their hire or appointment, all coaches are required to successfully complete a Coaching Eligibility Course, a Sport First Aid Program, and a CPR/AED Certifi cation Program. Athletic administrators take part each year in an orientation program for new athletic administrators designed to better prepare them for the day-to-day rigors of their jobs. In most sports, mandated rules clinics are conducted annually across the state for coaches. The MPA s educational efforts serve to better everyone involved in interscholastic athletics. More About the MPA! SAFETY An on-going concern of member schools is the wellbeing of their young athletes on and off the playing fi eld. The MPA is involved in a variety of safety issues. The MPA also provides schools with educational materials to better acquaint them about communicable diseases in athletics, and how to best deal with them. A leadership role is also taken by the MPA nationally to help develop competition rules which help keep injuries at a minimum and the levels of competition high. ACADEMIC Athletic participation is a critical component in the education of the majority of students attending the 153 MPA member schools. Research indicates: 95% of corporate offi cers recently surveyed had participated in high school athletics; student athletes have better grades than nonathletes; and student athletes have higher attendance rates and higher graduation rates than non-participants. SOCIAL For many students, high school sport programs provide the most stable environment in their lives. These programs often represent the best practices in: drop out prevention crisis intervention supervised activity and drug prevention programs that a community can provide. The cost is minimal (1%-3% of the local school budget) while the benefi ts are priceless. CHARACTER Within high school sport programs, young people learn the value of discipline, teamwork, sacrifi ce, respect, loyalty, time management, accountability, citizenship, and sportsmanship. They also learn the value of organizational skills, confi dence, leadership, commitment, effort, and the importance of a good work ethic. They enjoy team activities which will benefi t their future. Ethics, integrity, playing within the spirit of the rules, and good sportsmanship are all important parts of the fabric of the high school interscholastic program. 3

7 LINES OF AUTHORITY MPA Authority The authority of the MPA to organize and regulate interscholastic activities is derived from the responsibility each school assumes when it applies for and receives membership status. At that time, the school agrees to abide by the Constitution, Bylaws, rules, regulations, and procedures of the MPA. The principal is held solely responsible for the athletic programs within his/her school. Frequently Asked Questions Q. How do I file a complaint against a school I think has violated the rules? A. Any participant school by its representative, or MPA committee by majority vote of its members, or any game offi cial or supervisor may, for good cause, fi le with the MPA executive director a complaint alleging violation of the association s Code of Ethics or Rules Relating to Interscholastic Activities. Complaints made on behalf of student participants shall be made by the representative school system. The complaint made in writing and addressed to the MPA Interscholastic Management Committee must set forth the names of the complainant and the party or parties complained against; a concise statement of the nature of the complaint or violation; the date and place of occurrence; and the code or rule provisions alleged to have been violated. The complaint may be mailed or delivered to the MPA headquarters in Augusta. What happens next? Upon receiving a complaint, the MPA executive director will record the date and time of receipt and will proceed to investigate the facts. The director will present the complaint and his/ her summary statement at the next Management meeting or any special meeting called for that purpose. If the complaint is believed to be negotiable, the executive director or any designee appointed by the Management Committee will meet with the parties, arbitrate the claim, and report the outcome to the committee. If the attempt at a negotiated settlement fails, the complaint will be set for an adversarial hearing. Note: The Recruitment Policy has an additional process for negotiating recruitment violations. Q. What penalty may be imposed? A. Whenever a determination is made that a violation of the Code of Ethics or Rules Relating to Interscholastic Activities has occurred, the Management Committee may penalize the offending parties, according to the gravity of the offense, in the following manner: Issuance of a letter of admonition or reprimand. Placement of the offender on probationary status for a period of up to one year. Loss or withdrawal of awards related to the area of the offense. Suspension from participation in MPA-sponsored interscholastic activities up to 365 calendar days. Any combination of the above. Summaries of all actions wherein a violation of the Code of Ethics or Rules Relating to Interscholastic Activities has occurred shall be published in the MPA newsletter. 4

8 Local School District Authority While the MPA has authority to organize and regulate interscholastic activities at the state level, local decision makers establish policies and regulations which apply to their student athletes. Local lines of authority in Maine districts generally follow this pattern: Board of Education/School Committee Superintendent Principal Athletic Administrator Interscholastic Athletic Program Coaches Students Offi cials Support Personnel Related Organizations PLAYING RULES AND RULES MEETING ATTENDANCE A. Schools shall adhere to the playing rules adopted by the MPA to govern games and meets in baseball, basketball, competitive cheer, cross country, fi eld hockey, football, golf, ice hockey, lacrosse, soccer, softball, skiing, swimming and diving, tennis, track and fi eld, volleyball, and wrestling. B. The National Federation of State High School Associations publishes playing rule books for baseball, basketball, competitive cheer, cross country, fi eld hockey, football, ice hockey, lacrosse, soccer, softball, swimming and diving, track and fi eld, volleyball, and wrestling, and those codes shall be offi cial. Unless modifi ed in these regulations, the offi cial rules for golf shall be those of the United States Golf Association; women s lacrosse, U.S. Lacrosse endorsed by the NFHS; skiing, MPA s Interscholastic Skiing Rules; and tennis, United States Tennis Association, supplemented by the MPA Tennis Rule Book. C. Coaches or representatives of the school, as indicated in each sport bulletin, in baseball, basketball, competitive cheer, fi eld hockey, football, ice hockey, lacrosse, soccer, softball, swimming and diving, volleyball, and wrestling must attend a scheduled mandatory clinic. The penalty for non-attendance is explained in each sport bulletin and varies from a $35 fi ne to non-participation in the tournament. D. Recommendation forms for tournament officials submitted by the coaches are extremely important. Whether or not you are going to qualify for the tournament, you want the very best offi cials involved. 5

9 MPA CODE OF ETHICS FOR SECONDARY SCHOOL ACTIVITIES The Code of Ethics for Secondary School Activities has been developed for the purpose of stating the behavioral expectations of everyone involved with (secondary) school activities programs. Adherence to the Code is expected at all MPA sponsored or sanctioned activities. Reported consistent and/or fl agrant violations of the Code may result in punitive action by the MPA Interscholastic Management Committee if charges are substantiated at a hearing convened for that purpose. In order to promote desirable behavior and enhance the overall quality of secondary school activities programs for which the MPA has assumed responsibility, the following Code of Ethics shall be in effect: It is the duty of all concerned with secondary school activities programs to Cultivate awareness that participation in school activities is part of the total education experience. No one should either seek or expect academic privileges for the participants. 2. Emphasize sportsmanship, ethical conduct, and fair play as they relate to the lifetime impact on participants and spectators. 3. Develop an awareness and understanding of the rules and guidelines governing competition and comply with them in all activities. 4. Recognize the purpose of activities in school programs is to develop and promote physical, mental, moral, social, and emotional well-being of participants. 5. Avoid any practice or techniques which endanger the present or future welfare of a participant. 6. Avoid practices that encourage students to specialize or that restrict them from participation in a variety of activities. 7. Refrain from making disparaging remarks to opponents, offi cials, coaches, or spectators. 8. Encourage the development of proper health habits and discourage the use of chemicals. 9. Exemplify self-control and accept adverse decisions without public display of emotion. 10. Encourage everyone to judge the success of the activities programs on the basis of the attitudes of participants and spectators, rather than on the basis of a win or loss. Adopted by the MPA Membership: April 29, 1988; Revised: April 29, 1999 COACHES CODE OF ETHICS National Federation Coaches Association The function of a coach is to educate students through participation in interscholastic competition. An interscholastic program should be designed to enhance academic achievement and should never interfere with opportunities for academic success. Each student-athlete should be treated as though he or she were the coaches own, and his or her welfare should be uppermost at all times. Accordingly, the following guidelines for coaches have been adopted by the NFCA Board of Directors. The coach shall be aware that he or she has a tremendous infl uence, for either good or ill, on the education of the student-athlete and, thus, shall never place the value of winning above the value of instilling the highest ideals of character. The coach shall uphold the honor and dignity of the professional. In all personal contact with studentathletes, offi cials, athletic directors, school administrators, the state high school athletic association, the media, and the public, the coach shall strive to set an example of the highest ethical and moral conduct. 6

10 The coach shall take an active role in the prevention of drug, alcohol, and tobacco abuse. The coach shall avoid the use of alcohol and tobacco products when in contact with players. The coach shall promote the entire interscholastic program of the school and direct his or her program in harmony with the total school program. The coach shall master the contest rules and shall teach them to his or her team members. The coach shall not seek an advantage by circumvention of the spirit or letter of the rules. The coach shall exert his or her infl uence to enhance sportsmanship by spectators, both directly and by working closely with cheerleaders, pep club sponsors, booster clubs, and administrators. The coach shall respect and support contest offi cials. The coach shall not indulge in conduct which would incite players or spectators against the officials. Public criticism of offi cials or players is unethical. Before and after contests, coaches for the competing teams should meet and exchange cordial greetings to set the correct tone for the event. A coach shall not exert pressure on faculty members to give student athletes special consideration. A coach shall not scout opponents by any means other than those adopted by the league and/or state high school athletic association. SAFETY FIRST The greatest responsibility of any coach is to ensure the safety of the student athletes under his/her care. The following articles have been included to provide you with some basic rules and guidelines to help you protect your team. Many of these articles may be found in the National Federation of State High School Associations' Sports Medicine Handbook, Third Edition. CONCUSSIONS Even though most concussions are mild, all concussions are potentially serious and may result in complications that range from prolonged brain damage to death if not managed properly. An athlete who has a head injury should not return to play without evaluation by medical personnel. Do not allow any athlete to return to participation if he/she has any symptoms. If an apparent head injury occurs, even if uncertainty exists about the severity of the injury and whether a true concussion occurred, that athlete should not return to action until medical clearance is obtained. Even a seemingly minor head injury, often referred to as a ding or bell ringer, is now considered a true concussion and must be managed as such to avoid potential long-term consequences. Neither loss of consciousness, vomiting or amnesia is necessary for a head injury to be considered a concussion. 7

11 RECOGNITION A concussion, by defi nition, means to shake violently. A blow to the head that causes the brain to shake inside the skull and result in EVEN A BRIEF AND MILD alteration in brain function is considered a concussion. Although no obvious signs or symptoms may show up immediately, listed below are some of the symptoms that may suggest a concussion has occurred. Any of these should be taken seriously. Headache Dazed and vacant expression ( foggy ) Confusion Diffi culty with balance and coordination skills Diffi culty with concentration, memory and organizational skills Nausea and/or vomiting Amnesia Slurred and/or inappropriate speech Repeating the same questions or comments Apparent loss of consciousness Moves slowly and/or clumsily Unsure of game, score or opponent Forgets play responsibilities Double vision or blurred vision Increased sensitivity to light or noise Sleep diffi culties Increased irritability Hypersensitivity to light and noise Abnormal vision, hearing, smell and/or taste Excessive fatigue Abnormal sleep patterns Ringing in the ears Numbness and tingling Emotional problems, especially sadness and depression MANAGEMENT Immediate or Sideline Management Any athlete suspected of even a concussion should be removed from the game or practice immediately. An athlete should not return to activity after an apparent head injury, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. For apparently minor injuries, close observation of the athlete should continue for a few hours. The athlete should be sent for emergency care if symptoms seem serious, seem to worsen, or if other injuries are suspected. PREVENTION Make sure that helmets are fi tted properly and are regularly sent for inspection or reconditioning. 8

12 Football players should be taught to not initiate contact with the helmet and all athletes should follow the rules of the sport. Do not allow an athlete to return if he/she has any symptoms of concussion. Follow current guidelines on return to play following injury. RECOMMENDATIONS All coaches, athletes, administrators and parents should be made aware of the signs and symptoms of concussions, post-concussion syndrome and second-impact syndrome. See Heads-up reference for free coach s tool kit. Each school should have a standard policy in place regarding the management and return to play of the concussed athlete. For athletes participating in high-risk sports or with a history of previous concussion, baseline testing to establish individual abilities in memory, brain function tests and balance-oriented testing by qualifi ed medical personnel is recommended. This can then be used to assist in return-to-play decisions if an injury occurs. RETURNING THE ATHLETE TO PARTICIPATION The International Conferences on Concussion at Vienna (2001) and Prague (2004), have signifi cantly changed the thinking of proper management of head injuries in athletes. Some of the conclusions are highlighted below: The grading systems for concussions previously utilized are no longer considered useful in determining how serious an injury may be or in determining when an athlete can safely return to play. No symptom(s) or signs (including loss of consciousness or amnesia) accurately predict the severity of the injury or help decide when an athlete can return to play. New guidelines recommend monitoring the course of the symptoms and beginning a gradual return-to-play protocol when all symptoms have cleared. (See Table 8 Sideline Decision-making and Table 9 Return-to-play) There are now objective, validated methods of evaluating brain function in athletes to help physicians determine with greater confi dence when an athlete does seem to be clear of symptoms and can start through the graduated return-to-play regimen. These include questionnaires, various pencil-and-paper tests, balance tests, neurological and memory tasks, and computerized tests. Recognizing that athletes, with the mentality of playing through the pain, are not always totally candid about admitting symptoms, guidelines now recommend the use of these more objective methods to evaluate how an athlete s brain is functioning. Tests requiring little cost like Sideline Assessment of Concussion (SAC), Sideline Concussion Checklist (SCC), and Sport Concussion Assessment Tool (SCAT) have been shown to be helpful. Newer computerized neuro-psychological screening like ImPACT, CRI and Sentinel have also been shown to be helpful for physicians making return-to-play decisions. Guidelines further suggest that athletes playing high-risk or collision sports or with a history of previous concussions, should have these tests administered prior to the season to serve as a baseline in case an injury does occur. 9

13 Mental exertion appears to worsen and prolong concussion symptoms to the same degree as physical exertion. Therefore, the concept of cognitive rest should be adhered to in concussion management. This may involve a limited class schedule for several days following a concussion, or rescheduling tests. More severely concussed athletes may require more detailed and long-lasting special accommodations. A requirement to begin the return-to-play protocol is that the athlete must have no Symptoms. Then, gradual increase in mental activity as tolerated will be followed by a similar gradual return to full physical activity. If symptoms recur, then the athlete must regress to a previous level of performance. (See Tables 8 and 9 below) Table 8. Sideline Decision-making Sideline Decision-making 1. No athlete should return to play (RTP) after head injury even if clear in 15 minutes without medical clearance. 2. Any athlete removed from play for a head injury must have appropriate medical clearance before practice or competition may resume. 3. Close observation of athlete should continue for a few hours. 4. After medical clearance, RTP should follow a stepwise protocol with provisions for delayed RTP based on return of any signs or symptoms. Medical Clearance RTP Protocol 1. No exertional activity until asymptomatic. 2. When the athlete appears clear, begin lowimpact activity such as walking, stationary bike, etc. 3. Initiate aerobic activity fundamental to specific sport such as skating, running, etc. 4. Begin non-contact skill drills specific to sport such as dribbling, ground balls, batting, etc. 5. Then full contact in practice setting. 6. If athlete remains without symptoms, he or she may return to play. A. Athlete must remain asymptomatic to progress to the next level. B. If symptoms recur, athlete must return to previous level. C. Medical check should occur before contact. 10

14 Table 9. Return-to-play Return-to-play Medical Clearance Protocol No mental or physical activity should occur until athlete s symptoms are gone. Avoid physical exertion but also avoid studying, school attendance, test taking, video games, computer use and TV until clear. When clear, begin with short periods of reading, focusing and an abbreviated school day as tolerated. When tolerating full day of school attendance, begin low-impact activity such as walking, stationary bike, etc. Gradually increase intensity and duration as tolerated. Advance to aerobic activity fundamental to specific sport such as skating, running, etc. Advance to non-contact skill drills sports specific such as dribbling, batting, shooting. Full contact in practice setting. If accomplishes all the above without return of signs and symptoms, may return to play following final clearance. Some athletes, especially if multiple previous concussions, should consider having a baseline computerized neuropsychological test performed because of the increased risk of concussions in those with previous ones. MORE ON CONCUSSIONS Significance The initial recognition and management of concussions are particularly important in high school athletes in preventing two potential complications associated with concussions in this age group: post-concussion syndrome and second-impact syndrome (see page 81). Younger athletes may be at increased risk of cerebral swelling after a mild head injury with greater vulnerability for post-concussion symptoms for a longer period of time. Proper management should minimize the risk for these catastrophic results. Recognition of concussions Severity The severity or seriousness of a concussion is primarily based on how long the symptoms last. The number and severity of symptoms may have some correlation but no specifi c symptoms are more likely to help determine severity. Restricting mental and physical activity immediately after the concussion seems to correlate with a quicker return to play. 11

15 Signs and Symptoms of Concussions Coaches, administrators, offi cials, (See Table 10 below) parents and athletes need to be aware of the observable signs and reported symptoms of a concussion. Table 10. Signs and Symptoms of Concussions Signs observed by medical staff Player appears dazed Player has vacant facial expression Confusion about assignment Athlete forgets plays Disorientation to game, score, opposing team Inappropriate emotional reaction (laughing, crying) Player displays incoordination or clumsiness Player is slow to answer questions Loss of consciousness Any change in typical behavior or personality Repeating the same questions or comments over and over again Symptoms reported by athlete Headache Nausea Balance problems or dizziness Double or fuzzy vision Sensitivity to light or noise Feeling slowed down Feeling "foggy" or "not sharp" Change in sleep pattern Concentration or memory problems Irritability Sadness Feeling more emotional COMPLICATIONS ASSOCIATED WITH CONCUSSIONS Post-concussion Syndrome Following a concussion, athletes may suffer a number of lingering symptoms for varying lengths of time. Below are listed some of the more common symptoms that may last for weeks or months. Again, no athlete with any symptom related to head injury should even begin the return-to-play protocol. Impaired attention Fatigue Concentration and memory defi cits Irritability Dizziness Visual problems Tinnitus (ringing in the ears) Neurasthenia, weakness or numbness Prolonged or recurring headaches (especially with exertion)* *Often high school athletes may return to sport prematurely because the headache can mistakenly be seen as a common ailment. However, recent research has shown that athletes with residual headaches even a week post concussion do poorly on specialized tests such as reaction time and memory (Collins et al, 2003). It is imperative that even a seemingly non-signifi cant headache not be dismissed as a common ailment prior to returning to sports. 12

16 Second-Impact Syndrome Second-impact syndrome is a rare event, which poses a signifi cant concern for athletes who return too soon after suffering a previous concussion. Second-impact syndrome occurs when a second concussion occurs before a previous concussion has completely healed even if both of the injuries were very mild. Second-impact syndrome is characterized by an autoregulatory dysfunction that causes rapid and fatal brain swelling, and can result in death in as little as two to fi ve minutes (McCrory, 1998). It is particularly important to note that virtually all of the second-impact syndrome cases that have been reported have occurred in adolescent athletes. The signs of second-impact syndrome are as follows: Previous history of concussion Visual, motor or sensory changes Diffi culty with memory and/or thought process Collapse into coma Neurological abnormalities in strength, range of motion or sensory feelings. Cumulative Effects of Repeated Concussions A three-year, follow-up study shows that athletes having a previous history of at least one concussion are at an increased risk for further concussions. As the number of concussions increase, so do the risk for future injuries (Guskiewicz et al, 2003). It has also been shown that repeated concussions have been linked to longer recovery periods. Highlighting the importance of making sure athletes are symptom free prior to returning to competition from a previous MHI, research has shown that 1 in 15 athletes with a concussion have recurring concussions within 7-10 days from the fi rst concussion. Because of these fi ndings and the potential for complications resulting from MHIs, it is recommended that athletes sustaining more than one concussion should be referred for follow-up evaluation and assessment to determine any residual effects that might preclude participation in contact or collision sports. Cases of individuals suffering permanent brain damage from multiple concussions have been reported but no consensus on how many concussions are too many or what leads to that permanent damage. Medical Clearance to Return to Participation After Head Injury There is unanimous agreement within the medical community that NO athlete who has signs and symptoms of post concussion should be returned to action. There is also unanimity that there is increased risk of signifi cant damage from a concussion for a period of time after a preceding concussion and from cumulative damage of multiple head injuries. The more concussions an individual has, the greater is the risk of having additional concussions. The exact period of increased vulnerability or the number of concussions that is too many has not been determined. Traditionally, physicians have advised athletes not to return to action until they have been free of symptoms for a minimum of a week. (McCrea et al, 2003). Now, rather than discuss a length of time to be free of symptoms, guidelines suggest using the gradual return-to-play protocol shown above while monitoring the athlete for symptoms. This could be longer or shorter than a week. Research, utilizing some of the testing instruments mentioned above, is now revealing subtle residual effects of concussion not found by traditional evaluation. These identifi able defi cits frequently persist after the obvious signs of concussion are gone and appear to have relevance to whether an athlete can return to action with relative safety. 13

17 REFERENCES Alves W, Macciocchi SN, Barth JT. Postconcussive symptoms after uncomplicated mild head injury. Journal of Head Trauma Rehabilitation 1993; 8: Aubry M, Cantu R, Dvorak J, et al: Summary and Agreement Statement of the First International Symposium on Concussion in Sport, Vienna Phys Sportsmed 2002: 30(2): Cantu RC. Criteria for return to competition after a closed head injury. In: Torg JS, editor. Athletic Injuries to the Head, Neck, and Face. Second ed. St. Louis: Mosby Year Book; p Cantu RC. Posttraumatic Retrograde and Anterograde Amnesia; Pathophysiology and Implications in grading and Safe Return to Play. Journal of Athletic Training 2001; 36: Collins MW, Lovell MR, McKeag DB. Current issues in managing sports-related concussion. JAMA 1999; 282: Collins MW, Field M, Lovell MR, Iverson G, Johnston KM, Maroon J, Fu F. Relationship between postconcussion headache and neurophysiological test performance in high school athletes. American Journal of Sports Medicine 2003; 31(2): Colorado Medical Society Committee on School Health and Sports Medicine. Guidelines for the Management of Concussion in Sports. P.O. Box 17550, Denver CO : Colorado Medical Society; Guskiewicz KM, McCrea KM, Marshall SW, Cantu RC, Randolph C, Barr W, Onate JA, Kelly JP. Cummulative effects associated with recurrent concussion in collegiate football players. Journal of the American Medical Association 2003; 290(19): Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, & Valovich McLeod TC. National Athletic Trainers Association Position Statement: Sport-Related Concussion. Journal of Athletic Training. In Press, HEADS-UP Concussion in High School Sports, Free information for coaches, Dept of Health and Human Services CDC;. Kelly JP, Rosenberg, J.H. et al. Practice Parameter: The management of concussion in sports (summary statement). American Academy of Neurology Quality Standards Subcommittee. Neurology. 1997; 48(3): McCrea M, Guskiewicz KM, Marshall SW, Barr W, Randolph C, Cantu RC, Onate JA, Yang J, Kelly JP. Actue effects and recovery time following concussion in collegiate football players. Journal of the American Medical Association 2003; 290(19): McCrory PR, Berkovic SF. Second impact syndrome. Neurology 1998; 50: McCrory P, Johnston K, et al: Summary and Agreement Statement of the Second International Conference on Concussion in Sport, Prague Clinical Journal of Sports Medicine. March 2005; Perriello, V, Suggested Guidelines for Management of Head Injury in Sports, org; National Federation of State High School Associations and the NFHS Sports Medicine Handbook, Third Edition. 14

18 PRE-HOSPITAL CARE OF SPINAL INJURIES The Sports Medicine Committee of the Maine Principals' Association (MPA) feels there needs to be standardized guidelines to be used by all providers in the pre-hospital care of spine-injured athletes. The MPA has reviewed and is in complete agreement with the guidelines and recommendations published by the National Athletic Trainer's Association (NATA) in 2001, and updated in 2007*, concerning the prehospital care of the spine-injured athlete. Controversy exists regarding helmet removal in spine-injured football players. In part, this controversy stems from the accepted practice of helmet removal from motorcycle riders who suffer injuries to the spine. Generally, these helmets are removed by medical personnel after an accident to ensure control of the airway. Motorcycle helmets usually do not have a removale facemask, are not worn with shoulder pads, and do not snggly fi t the head. Therefore, they are removed prior to transportation to achieve neutral spine alignment and insure adequate stabilization of the injured motorcyclist on a spine board with obstructed access to the airway. In contract, a properly fi tted football helmet will hold the head in a position of neutral spine alignment, provided the athlete is wearing shoulder pads. Access to the airway is easily obtained by removing the facemask. Therefore, the MPA and Intra-Association Task Force of the NATA recommend that neither the football helmet nor shoulder pads be removed prior to transportation of a spine-injured athlete, unless the airway can not be controlled and/or spine immobilized with the helmet and shoulder pads in place. This recommendation is in agreement with the Maine EMS Prehospital Treatment Protocols**. * Kleiner DM, Almquist JL, Bailes J, Burruss P, Feuer H, Griffi n LY, Herring, S, McAdam C, Miller D, Thorson D, Watkins RG, Weinstein S. Prehospital Care of the Spine-Injured Athlete: A Document from the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete. Dallas, Texas, National Athletic Trainers' Association, March ** Protective Headgear removal; Section Gray, Article 27; Mfaine EMS Prehospital Treatment Protocols. Maine Emergency Medical Services, 152 State House Station, Augusta, ME Effective July 1, REDUCING BRAIN AND SPINAL INJURIES IN FOOTBALL Frederick O. Mueller, Ph.D. and Robert C. Cantu, M.D., University of North Carolina Brain and spinal injuries in football have been dramatically reduced since the rules were changed in 1976 to prohibit butt blocking and face tackling, and any other technique in which the helmet and facemask purposely received the brunt of the initial impact. There are still a small number of football players (and fewer in other sports) that become paralyzed, but the lesson to keep the head and face out of blocking and tackling remains. Generally, about 3-5% of the injuries experienced by participants in athletics are concussions, e.g., temporary dizziness, confusion, nausea, headaches, and perhaps unconsciousness. Concussions are given grades from Grade 1 (a hit that dazes for a few minutes) to Grade 3 (unconscious). No concussion should be dismissed as minor until proven so by medical personnel. The task is to be sure that the athlete no longer has any post-concussion symptoms at rest and exertion before returning to competition. What is now called "the second impact syndrome" with its high rate of morbidity if not mortality, is the result of returning to play too soon. 15

19 Several suggestions for reducing brain and spinal injuries follows: 1. Preseason physical exams should be required for all participants. Identify during the physical exam those athletes with a history of previous brain or spinal injuries. If the physician has any questions about the athlete s readiness to participate, the athlete should not be allowed to play. 2. A physician should be present at all games and practices. If it is not possible for a physician to be present at all games and practice sessions, emergency measures must be provided. The total staff should be organized in that each person will know what to do in case of a brain or spinal injury in game or practice. Have a plan ready and have your staff prepared to implement that plan. Prevention of further injury is the main objective. 3. Athletes must be given proper conditioning exercises which will strengthen their neck muscles in order for them to be able to hold their head fi rmly erect when making contact. Strong neck muscles help prevent neck injuries. 4. Coaches should drill the athletes in the proper execution of the fundamentals of football skills, particularly blocking and tackling. KEEP THE HEAD OUT OF FOOTBALL. 5. Coaches and offi cials should discourage the players from using their heads as battering rams. The rules prohibiting spearing should be enforced in practice and in games. The players should be taught to respect the helmet as a protective device and that the helmet should not be used as a weapon. 6. All coaches, physicians, and trainers should take special care to see that their players equipment is properly fi tted, particularly the helmet. 7. Strict enforcement of the rules of the game by both coaches and offi cials will help reduce serious injuries. 8. When a player has experienced or shown signs of brain trauma (loss of consciousness, visual disturbances, headache, inability to walk correctly, obvious disorientation, memory loss) he/she should receive immediate medial attention and should not be allowed to return to practice or game without permission from the proper medical authorities. Coaches should encourage players to let them know if they have any of the above mentioned symptons (that can't be seen by others, such as headaches) and why it is important. 9. Both athletes and their parents should be warned of the risks of injuries. 10. Coaches should not be hired if they do not have the training and experience needed to teach the skills of the sport and to properly train and develop the athletes for competition. Following is a list of post-concussion signs/symptoms: Depression, numbness/tingling, dizziness, poor balance, drowsiness, poor concentration, excess sleep, ringing in the ears, fatigue, sadness, feel "in fog", sensitive to light, headache, sensitivity to noise, irritability, trouble falling asleep, memory problems, vomiting, nausea, and nervousness. 16

20 RECOGNITION AND MANAGEMENT: COLD ILLNESS, HEAT ILLNESS, AND HYDRATION Hypothermia: A decrease in core body temperature Mild hypothermia - shivering, cold sensation, goosebumps, numb hands. Moderate hypothermia - intense shivering, muscle incoordination, slow and labored movements, mild confusion, diffi culty speaking, signs of depression, withdrawn. Severe hypothermia - Shivering stops, exposed skin is bluish and puffy, inability to walk, poor muscle coordination, muscle rigidity, decrease in pulse and respiration rate, unconsciousness. Management: Remove athlete from cold environment. Remove wet clothing and replace with dry clothing and/or blankets. Refer all moderate cases to the emergency room once safe to transport. Treat severe hypothermia as a medical emergency! Wrap the athlete in an insulated blanket and seek emergency medical care immediately. Frostbite: Thermal injury to the skin caused by cold exposure: (See Figure 1 - Wind Chill Index) Frostnip - Skin appears white and waxy or gray and mottled; possible numbness and pain. Superficial frostbite - Skin appears white, mottled, or gray; feels hard or rubbery but deeper tissue is soft, insensitive to touch. Deep frostbite - Skin is white and has a wooden feel, numbness, and anesthesia. Management: Do not rub the area. Gently rewarm the area by blowing warm air onto the area, placing the area against a warm body part, or placing the affected area into warm (101 deg deg. F) water for several minutes. If not absolutely certain that the tissue will stay warm after rewarming, do not rewarm it. Refreezing newly thawed frostbitten tissue can cause extensive tissue damage! If a person is also suffering from hypothermia, the fi rst concern is core rewarming. Prevention: The best method of management is prevention. Dress in layers. Cover the head to prevent excessive heat loss from the head and neck. Stay dry by wearing a wicking fabric next to the body and a breathable, water repellent outer layer. Stay adequately hydrated. Eat regular meals. Avoid alcohol, caffeine and nicotine. Educate participants, coaches, offi cials and administrators in recognition of cold-related illnesses. Consider cancellation of athletic events if weather conditions warrant. If unsure whether an athlete is hypothermic, err on the side of caution and treat accordingly. National Federation of State High School Associations and the NFHS Sports Medicine Handbook, Third Edition 17

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